Reflux, like Superman, is a bit of a mystery to most. Where did it come from? What makes it stronger? Most importantly, what is reflux's kryptonite? Unfortunately, in our case, reflux isn't the hero but the villain.
The first step to figuring out reflux's kryptonite is a surprising one to many. It's figuring out if it is *actually* reflux! And that looks like a job for Moms.
You may be thinking, "What do you mean...ACTUALLY reflux? What else could it be?" We all know that Superman is really Clark Kent, but what many don't don't know is that reflux is *often* aerophagia.
Aerophagia
Aero-what, you ask? Aerophagia is a fancy way of saying “swallowed air”. The thing is, every single one of us swallows SOME air. The stomach is a muscle and can grow and expand...up to a certain amount. In the case of aerophagia, the stomach fills with too much air rather than (or in addition to) food.
To a certain extent, our body is made to handle this pressure. But the time comes that the pressure is just too much. You can think of it like filling an untied balloon. If you add air, it'll grow and expand to the size it's supposed to be without issue. When it comes to aerophagia, take that same balloon but, this time, overfill it with air. The pressure becomes too much and when you go to tie the balloon the extra air will likely shoot up and out. Luckily, just like balloons,our bodies have an opening that can let that excess air out in the form of regurgitation, vomit, spit up, hiccups, burps, and farts. The opening at the top is called the lower esophageal sphincter and it keeps our stomach contents in the stomach. In the case of aerophagia, the excess air can sometimes be mistaken for reflux and overtime can actually cause reflux.
Now, before you take a deep dive into this, I need you to know it's a lot. If you want a warm and fuzzy, feel-good story on reflux, this isn't it. If you're tired of your baby's constant reflux and are determined to find answers, this is for you. As you move forward please know that some of it may pertain to your little one while some of it may be irrelevant. Each person is unique so it's important to figure out what works for them individually.
What does aerophagia look like? Aka Does my baby have reflux?
Aeropagia looks a lot like reflux. These babies often present with colic-like symptoms, including crying and discomfort with feeding. Oftentimes, babies will have a bloated stomach, abdominal distension, cry while eating, and have excessive burps, belches, hiccups, spit ups and farts. We're not talking about the occasional spit up here or there, but rather the, "I hate taking my baby in the car because I have to clean the spit up off the walls" or "I'm tired of doing the laundry because of the towels we use for cleaning up vomit." Almost all babies under the age of 3 months will spit up a little bit here and there if they overeat or are stressed…a small amount of spit up is normal! If it's not a regular occurrence, don't worry about it. If it's a daily occurrence, forceful or causes more distress, this is when it becomes an issue we need to look out for.
Aerophagia babies can also be seen through observation as they frequently arch their back and look like the letter "c". If they sit in a car seat, their head may be twisted or looking up at the sky. When/if they sleep, you'll notice their head tilted up with their jaw pointed upwards. Or maybe you've said they are "really strong for their age" and lift their heads up from birth or roll over before 4 months old. But here's the catch, that strength is actually a sign of tension. Newborns aren't supposed to be able to lift their heads or roll. It's actually developmentally inappropriate for a 6 week old to roll over.
Aerophagia vs reflux...how do I know if my baby has reflux or aerophagia?
One of the big giveaways to reflux vs aerophagia is the smell. If the baby's spit-up smells rancid or acidic, then it is more likely to be true reflux. If it doesn't smell a lot, then it is more likely to be aerophagia because the milk isn't settling and mixing with the gastric juices and acid.
We can also look at the history of the baby while eating, both bottle and breast. If there's a history of tongue ties, painful latch (mom clenching her jaw or curling her toes in pain or resisting the urge to squeeze baby's head because of pain) these can be signs of a poor latch which can let air in. Also, clicking while drinking, nursing forever (or taking only short breaks), poor seal around the nipple of bottle or breast (corners of the mouth should be fully sealed around nipple), fussiness during or after feeding are considered a latch issue which can cause the aerophagia.
We can also tell based on some symptoms. By definition, reflux is stomach acid or bile irritating the lining. Reflux typically worsens the more it happens and one of the easiest ways to know this is by listening to your little one's cry. As horrible as it is for you to listen to, if your baby's cry becomes more raspy and gurgling, then they most likely have reflux. If your little one is always hiccuping, burping or yawning or would make a grown man blush with their farts, this is a sign of aerophagia and excess gas rather than reflux..
Another way is through a bit of trial and error. If your little one has been taking proton pump inhibitors and hasn't improved, there's a good chance they actually have aerophagia. Or if the baby developed a cough without improvement while taking PPI, this may indicate aerophagia or aerophagia-induced reflux.
What causes reflux and aerophagia and how can I help my baby?
This part is probably the most important because once you find out the why(s), you can help your baby a whole lot faster. Now here's the tricky part…oftentimes there isn't ONE cause but a collection of things that once added together, are too much for the body to handle.
Overtime as the different components of aerophagia add up, more symptoms can occur. True reflux, where acid is being regurgitated, can be caused by aerophagia. Chronic aerophagia can also lead to increased constipation and stress which can add to the risk of reflux. Unfortunately all of these stressors can change how the body handles that pressure and the symptoms get worse rather than better. This is because there's an increase in pressure on the lower esophageal sphincter that overcomes the strength/tone of the sphincter and leads to the sphincter being open longer (aka that balloon is losing all of its air rather than just the excess air). As the body becomes more stressed, it also becomes more sensitive to inflammation, irritation and distension which can cause more reflux.
As doom and gloom as that last paragraph sounds, I want you to know there is also hope. So I want you to look at a few reasons why babies may experience aerophagia and how to best support them based on what you are seeing:
Tongue and lip ties: The things mentioned below are not exclusive to a tongue and lip tie but common with them which is why I listed them underneath.
Poor latch: an Improper latch does not mean a baby is tongue tied as there are many causes for a poor latch. But if you frequently see your baby nursing from the bottle or breast and the edges of their mouth form a “v-shape” with open gaps rather than “c-shaped” lips gathering the entire nipple, this can be a sign of limited tongue mobility. If your baby can't open their mouth wide (lips stay mostly closed or pursed together) or close their mouth, pops on and off the breast, you experience nipple pain in between feeds, your nipple is a different shape/color after feeding, you hear them gulping milk or gasping for air during feeding or they are chugging and noisey while at the breast, there's milk pouring out the sides of their mouth or you feel like your baby feeds ALL of the time or for extended periods (or short periods but frequently), you frequently have mastitis or clogged ducts or your baby has a white coat on the top of their tongue, all of these are a sign of breastfeeding dysfunction. It's best to connect with both an IBCLC trained in oral ties AND a speech pathologist trained in feeding therapy and myofunctional therapy to get to the root cause.
Open mouth breathing or tongue on floor of mouth: When you look at your baby their mouth should be closed unless they are actively using it to communicate or eat. If you look at your baby while they are playing, doing tummy time, sleeping or in the car seat and you see their mouth is open or their tongue is on the floor of the mouth, this is a sign that needs to be looked at by a speech therapist trained in myofunctional therapy to assess tongue function, bodyworker trained in oral ties (this can be an OT, PT, DC, CFT/Gillespie, CST, osteopath) If the bodyworker or SLP cannot make improvements, then a referral to pediatric ENT is warranted to ensure they are able to breathe through their nose.
Excessive crying, sighing and hiccuping: Excessive crying can be a sign of nervous system dysfunction which can further increase the risk of reflux and aerophagia. If you find your baby is frequently distressed or sighing and hiccuping, I recommend a speech pathologist trained in myofunctional therapy and a bodyworker trained in diaphragm release for infants (OT, PT, DC, CFT/Gillespie, CST, osteopath, PRI-trained provider)
Cranial dysfunction: You may be wondering what I mean by this but if you have noticed that your beautiful little baby is a little asymmetrical (one eye bigger or wider than the other, one ear further away from the head, one nostril smaller than the other, jaw tilted to one side) this can be a sign of cranial dysfunction. Cranial dysfunction can influence how both the muscles and nerves of the tongue, face and airway work which can be addressed by a chiropractor trained in cranial work or an osteopath.
Torticollis and plagiocephaly: Take a deep breath in and focus on your throat. How do you feel? Now, tilt your head to one side and look up. How does it feel? When our little ones have torticollis (head preference to one side) or plagiocephaly (flattening of one side), it can make it more difficult to breath freely so they are more likely to take in excess air. This is where a PT, OT, and chiro trained in motor development comes in handy.
Posture while feeding: There's a breastfeeding saying of “nose to nipple” which helps the baby slightly look up to open the mouth to latch. This is helpful because it helps open the airway. If you find your baby's chin is tucked to their chest, it will be harder for them to swallow. It’s also important to support the baby so that their butt, shoulders and the middle of their ear are relatively aligned. This may require lots of pillows but it helps support the baby so they can eat in a more relaxed and comfortable way. If you notice any discomfort or struggle to get a comfortable position while feeding, find an IBCLC trained in ties. If you are “doing everything right” and the baby still has symptoms, reach out to a speech therapist or OT trained in myofunctional therapy for evaluation.
Sleep disordered breathing and sleep apnea: This goes hand and hand with open mouth breathing, but if you notice your baby thrashes or jolts in their sleep, seems excessively tired or wired compared to kids their age, snores or breathes loudly in their sleep, they may have SDB. My first recommendation is again a SLP trained in myofunctional therapy and they can make the appropriate referral to a pediatric ENT or airway focused dentist based on how your baby is presenting.
Excessive gag reflex: All newborns should have a gag reflex BUT it should not be activated if you gently slide your finger or nipple into their mouth. They should be able to take your finger into their mouth without gagging. If they can't this is something that should be addressed by an OT, Chiro, SLP, PT, or myofunctional therapist trained in oral assessment and treatment.
Improper bottle feeding
Shaking formula/bottle too much: This sounds pretty straight forward but when making a bottle, make sure you gently mix the formula and stir the breastmilk to ensure the heat is consistent. Shaking the bottle too much can increase aerophagia so make sure you are gently swirling the bottle to limit the addition of air into the milk.
Wrong nipple on bottle: Some kids do really well with a premi nippe or the newborn nipple because it has a slower flow. Other kids that struggle with ties may require a greater flow because they don't have the muscle control to appropriately suck. You can limit this by trying different nipples and bottles. There is not a magic bottle that works for everyone so it will take time to figure out what works for your little one.
Posture while feeding: see above
Secondhand smoke
Genetic predisposition to connective tissue disorder:
As the lower esophageal sphincter is a muscle, if you have a connective tissue disorder like Ehlers Danlos or hypermobility, it is common for the sphincter to also be hypermobile and have a delayed closure and decreased endurance so the risk of aerophagia and reflux are increased. While we can't change the connective tissue and muscle, we can make sure all developmental milestones are met and pediatric physical therapists or chiropractors trained in motor development like DNS are helpful to help ensure optimal motor development.
Nervous system dysregulation:
I'm not going to lie, I wish this one wasn't part of aerophagia or reflux. Unfortunately, both acute and chronic stress can alter the lower esophageal sphincter. When the body is under stress, emotionally and/or physically, it naturally decreases vagal tone which makes the body hypersensitive to inflammation, irritation and distension. Stress also decreases the nerve function to the intestines, making it more susceptible to dysbiosis, food allergies, cellular damage to GI tract, and constipation which can all increase the risk of reflux. The best way to support a baby's nervous system is through co-regulation. In the newborn age, this means taking care of your emotional and mental needs, skin-to-skin and all of the snuggles you can give. If you notice that you are struggling to regulate, this is also a time to lean into any community you have and ask for help with dishes, laundry, meals, etc.
Neurodivergence:
Studies have shown that Neurodivergent people (autistic, ADHD, Sensory processing disorder) are more likely to have reflux and/or aerophagia. This is likely attributed to two things that are common in the ND community, sleep issues and open mouth breathing. If this sounds like your little one, the two best recommendations I can give are a speech pathologist trained in myofunctional therapy or a sensory based OT (DIR floortime, Ayers Sensory,etc).
Premature birth → aerophagia and reflux are both common in kids that are born prematurely because of:
Decreased sphincter control: at the time of birth the lower esophageal sphincter hasn't fully developed and premature babies have lower resting tone compared to non-premature babies. If your baby requires a NG tube, this can also alter the sphincter and make it more likely to stay open allowing more air and acid into the esophagus.
Low vagal tone: low vagal tone is similar to nervous system dysregulation but can also be caused by stress, congenital or acquired neurological conditions, birth trauma, tongue dysfunction not properly activating the vagus nerve, cranial and cervical dysfunction not allowing optimal conductance of the nerves.
Decreased tongue strength and endurance: just as every other muscle of the body has low tone, so do the muscles of the tongue and airway. In fact, we can see babies on ultrasound doing a coordinated suck-swallow-breathe pattern arrive 32 weeks with improved function after 34 weeks. Babies that born before 32-34 weeks are more likely to have a decreased suck-swallow-breathe pattern and are more likely to take in air.
Inability to breathe through the nose:
This can be from structural limitations like a deviated septum (up to 20% of newborns may have one), small nasal passages (see cranial dysfunction above), or nasal congestion (see environmental factors below). If your baby is not able to breathe through their nose, a pediatric ENT is the first person to reach out to. There are over-the-counter medications that may be recommended like Xclear nasal spray or olbas nasal spray or it may require more extensive care based on how your baby presents.
Environmental factors influencing respiration:
This can be anything from mold exposure to allergies (environmental and food) and asthma. Oftentimes when someone is congested or struggling to get enough oxygen due to these things, they will naturally swallow air as they are taking big gasps trying to get oxygen rather than normal slow breaths. If you suspect this of your child, I'd recommend first doing a 3 week trial of dairy and gluten removal. If it persists or your baby presents with a rash, eczema or increased congestion, finding an allergist and/or functional medicine provider can be very helpful. If your baby has red or black poops, a pediatric gastroenteritis and allergist should be on the top of your list for people to see.
Anatomical anomalies of esophagus, lower esophageal sphincter and abdomen (hernia):
This one definitely requires the help of a gastroenterology or pediatrician. But if you notice a bulge in your baby's belly or around the belly button, it can be a sign of a hernia and should be monitored by your pediatrician. If your baby was previously feeding okay and is now projectile or forcefully vomiting or can't keep anything down, please head to the ER as this is a sign of pyloric stenosis which needs to be treated right away.
Alright, if you've made it this far, take a deep breath in and a long exhale. I know having a baby that is struggling with reflux or aerophagia can feel overwhelming and exhausting. You are not alone and there is support out there to help you find your little one's kryptonite for their reflux.
